OAKLAND, Calif. — The kitchen counter in the Hayes family’s home is scattered with the inhalers, sprays and bottles of pills that have allowed Hannah, 13, and her sister, Abby, 10, to excel at dance and gymnastics despite a horrific pollen season that has set off asthma attacks, leaving the girls struggling to breathe.

Asthma — the most-common medical condition that affects about 40 million Americans of all ages — usually can be controlled with drugs. But being able to afford prescription medications in the United States often requires top-notch insurance or plenty of disposable income, and time to hunt for deals and bargains.

The arsenal of medicines in the Hayeses’ kitchen helps explain why.

Pulmicort, a steroid inhaler, retails for more than $175 in the U.S., while pharmacists in Britain buy the same product for about $20 and dispense it free of charge to asthma patients.

Albuterol, one of the oldest asthma medicines, typically costs $50 to $100 per inhaler in the United States, but it was less than $15 a decade ago, before it was repatented.

“The one that really blew

my mind was the nasal spray,” said Robin Levi, Hannah and Abby’s mother, referring to

her $80 co-payment for Rhinocort Aqua, a prescription drug that sold for more than $250 a month last year but costs less than $7 in Europe, where it is available over the counter.

The Centers for Disease Control and Prevention puts the annual cost of asthma in the U.S. at more than $56 billion, including millions of potentially avoidable hospital visits and more than 3,300 deaths, many involving patients who skimped on medicines or did without.

“The thing is that asthma is so fixable,” said Dr. Elaine Davenport, who works in Oakland’s Breathmobile, a mobile asthma clinic whose patients often cannot afford high prescription costs. “All people need is medicine and education.”

The United States spends far more per capita on medicines than other developed countries. Drugs account for

10 percent of the country’s

$2.7 trillion annual health bill, said Gerard Anderson, who studies medical pricing at the Bloomberg School of Public Health at Johns Hopkins University.

While prescription-drug spending fell slightly last year, in part because of the recession, it is expected to rise sharply as the economy recovers and as millions of Americans become insured under the Affordable Care Act, said Murray Aitken, the executive director of IMS Health, a leading tracker of pharmaceutical trends.

‘A frustrating saga’

Hannah and Abby Hayes were admitted to the hospital on separate occasions in 2005 with severe shortness of breath. Oakland is subject to pollution from its freeways and a busy seaport.

The asthma rate nationwide among African-Americans and people of mixed racial backgrounds is about 20 percent higher than the average.

Robin Levi, a Stanford-trained lawyer who works for Students Rising Above, a group that helps low-income students attend college, is black. Her husband, John Hayes, an economist, is white. Their daughters have allergic asthma that is set off by animals, grass and weeds, but they also get wheezy when they have a cold.

While on medication, neither Hayes girl has been in the hospital since her initial diagnosis. Their mother tweaks dosing, adding extra medicine if they have a cold or plan to ride horses.

For most patients, asthma medicines are life-changing. In economic terms, that means demand for the medicines is inelastic. Unlike a treatment for acne that a patient might drop if the price became too high, asthma patients will go to great lengths to obtain their drugs.

Patent plays

Dr. Dana Goldman, the director of the Leonard D. Schaeffer Center for Health Policy and Economics at the University of Southern California, said: “Producing these drugs is cheap. And yet we are paying very high prices.” He added that because inhalers were so effective at keeping patients out of hospitals, most national health systems made sure they were free or inexpensive.

But in the United States, even people with insurance coverage struggle.

Lisa Solod, 57, a freelance writer in Georgia, uses her inhaler once a day, instead of twice, as usually prescribed, because her insurance does not cover her asthma medicines.

John Aravosis, 49, a political blogger in Washington, buys a few Advair inhalers at $45 each during vacations in Paris, because his insurance caps prescription coverage at $1,500 per year.

Sharon Bondroff, 68, an antiques dealer in Maine on Medicare, scrounges samples of Advair from local doctors.

Bondroff remembers a time, not so long ago, when inhalers “were really cheap.” The sticker shock for asthma patients began several years back when the federal government announced that it would require manufacturers of spray products to remove chlorofluorocarbon propellants because they harmed the environment. That meant new inhaler designs. And new patents. And skyrocketing prices.

As drugs age and lose patent protection, the costs of treatment can fall significantly because of generic competition.

Obstacles for generics

A result is that there are no generic asthma inhalers available in the United States. But they are available in Europe, where health regulators have been more flexible about mixing drugs and devices and where courts have been quicker to overturn drug-patent protection.

The FDA acknowledges that the lack of inhaled generic medicines, as well as topical creams, has been costly for patients, but it attributes that to “difficult, longstanding scientific challenges,” because measuring drug activity deep into the lung is complicated, said Sandy Walsh, a spokeswoman for the agency.

Dr. Robert Lionberger, the agency’s acting deputy director in the office of generic drugs, said research into the development of generic inhaled medicines was the agency’s highest priority but the effort had been stalled because of budget cuts imposed by Congress.

Even so, experts say,

a significant problem is that none of the agencies that determine whether medicines come to market in the United States

is required to consider

patient access, affordability or need.

“Drug patents are easy to get, and the patent office is deluged,” said Dr. Aaron Kesselheim, a pharmaceutical policy expert at Harvard Medical School. “The FDA approves based on safety and efficacy. It doesn’t see its role as policing this process.”

For asthma patients in the United States, the best the market has yielded are a few faux generics that often are only marginally cheaper than the brand-name versions.

Research vs. marketing

There are good reasons drug companies are feeling threatened. In the past several years, some best-selling medicines, such as Lipitor for high cholesterol and Plavix for blood thinning, have been largely replaced by cheap generics in a very competitive market. In 2012, that led to $29 billion in savings for patients, said Aitken of IMS, or $29 billion in lost revenues for drugmakers. Eighty-four percent of prescriptions dispensed last year were for generic medications.

Drug prices in the United States are set in hundreds of negotiations by hospitals, insurers and pharmacies with drug manufacturers, with deals often brokered by powerful middlemen called group-purchasing organizations and pharmacy-benefit managers, who leverage their huge size to demand discounts. The process can get nasty; if mediators offer too little for a given product, manufacturers might decide not to produce it or permanently drop out of the market, reducing competition.

With such jockeying determining supply, products can simply disappear and prices for vital medicines can fluctuate far more than they do for a carton of milk.